To request an appointment, please full out the form below
Title*
First Name*
Last Name*
Address*
Postcode*
Email*
Mobile Number*
Occupation*
Gender* MaleFemale
DOB* 12345678910111213141516171819202122232425262728293031 / 123456789101112 / 2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901
Do you have or have you ever suffered from:
Rheumatic fever?* YesNo
Any heart complaint. heart surgery or stroke ? YesNo
Diabetes? YesNo
Epilepsy or fainting attacks ? YesNo
Chronic bronchitis or asthma ? YesNo
Hepatitis ? YesNo
Excessive bleeding ? YesNo
High blood pressure ? YesNo
Any other serious illness ? YesNo
Do you carry a medical warning card ? YesNo
Are you allergic to any medicine, tablets, substances or latex ? (list below in notes) ? YesNo
at present taking any medicine or tablets (list below in notes ) YesNo
In past 2 years have you undergone any operations ? YesNo
Been treated with hydro cortisone or corticosteroids ? YesNo
Have you ever had a joint replacement operation ? YesNo
Please tick or tell the dentist if you are HIV positive ? YesNo
What is your average weekly consumption of alcohol ?
if you smoke, what is your average per week ?
if yes to any question please supply details in notes below
Name and address of your doctor (If you only know the practice name, please enter this. If you are not registered anywhere, please put N/A) :
Notes (please use this box to let us know any medication you are taking, any allergies you have and if there is any treatment in particular you are enquiring about):
Please select the most appropriate box:
If you went for your dentist appointment tomorrow, how would you feel?
Not anxiousSlightly anxiousFairly anxiousVery anxiousExtremely anxious
If you were sitting in the waiting room (waiting for treatment), how would you feel?
If you were about to have a tooth drilled, how would you feel?
If you were about to have your teeth scaled and polished, how would you feel?
If you were about to have a local anaesthetic injection into your gum, above an upper back tooth, how would you feel?
If you are not sure of any of the questions or if your medical circumstances change, please inform the Dental Surgeon
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